A Vegan Adolescent

01/11

We present Shelley, a Canadian girl who for the past two years has been a vegan. She has been moderately active. She walks to school and participates in dance classes most evenings and weekends. She admits to no smoking and to no use of alcohol. As she is fair-skinned, she uses sunscreen regularly.

02/11

Shelley has a sensitive nature, and her love of animals led her to become vegetarian at the age of 12 by avoiding meat. When she was 13 she became vegan by deciding she would not consume any animal products, as endorsed by various celebrities whom she admires. However, her parents disagreed with her dietary choices as it made meal planning and preparation complicated. They continued to make usual meals for themselves and her brother. They let her choose her own foods from the meals they prepared for the rest of the family.

03/11

Shelley's past medical history is unremarkable. Her parents are free from chonic disease but her maternal grandmother has osteoporosis.Her visit to the doctor's office is to investigate pain in her foot which began two weeks prior. Shelley complained of a foot pain that made dancing and walking to school difficult. Her parents felt this problem was serious enough to warrant a doctor's examination.

04/11

Shelley's Height is 5'2'' (1.61m) which places her at the 25 th percentile using CDC chartsHer Weight is108 lbs (60kg) -> 30th percentile using DCD chartShe has a Moderate activity levelA blood test was ordered which revealed a serum 25-hydroxyvitamin D level of 45 nmol/L, well below 75 nmol/LLooking at her growth chart, first we see that from age 12 to now, at age 15 years, both Shelley's weight and height have not kept up with growth, in terms of precentile trajectories. She is now at the 25th percentile for height, while at 12 years of age she was at the 55th percentile. Similarly for weight, she is now at the 30th percentile yet at age 12 she was 45th percentile.

05/11

Shelley's physician ordered an X-ray of her foot, which was negative for an obvious bone fracture.However on consultation with an orthopedic surgeon, the bone scan showed a stress fracture of the second metatarsal.She was given crutches and told to rest her foot. As she mentioned being vegan, a consult with a dietitian was ordered.

06/11

This slide shows a typical day's intake, where Shelley met her energy needs after a strenuous dance class. Although energy needs were sometimes met, the foods chosen were not always high nutrient quality. For example, there was a large salad, and many instances of eating fruit, but protein sources were lacking. When eating with her family she would choose only the foods that contained no animal products. As Shelley was vegan, she avoided dairy foods. Her beverages were often soft drinks, and she added extra calories as a chocolate bar.

07/11

The results of the dietary analysis show that as a vegan, Shelley's diet has many deficiencies as high quality vegan foods were not specifically chosen. Levels are compared to the Institute of Medicine Recommended Dietary Allowances for adolescents.Nutrients neede for bone that are inadequate for Shelley include protein, calcium, vitamin D and vitamin B12. Further, there would be low iron and zinc.All of these dietary factors that are missing have a detrimental impact on bone health, especially in Shelley as she is accruing bone an adolescent.

08/11

A bone density test revealed a Z-score of -3.3 in the spine, and -1.7 in the hip These put Shelley at high risk for not achieving significant peak bone mass which in later years will predispose her to osteoporosis

09/11

The dietary recommendations are as follows:A calcium source is needed; as Shelley continues to avoid animal products, two servings of a fortified plant-based beverage with added calcium and vitamin D is recommended.To ensure a high quality protein source, legumes such as lentils and chick peas could be added to salads and soups; her family could incorporate more of these meat alternatives into their own eating style. These protein and calcium and protein sources can be added to her school lunches.A vitamin D supplement is recommended to bring her serum 25-hydroxyvitamin D levels over 75 nmol/L.A multivitamin is recommended to provide B12, iron and zinc

10/11

At follow up one month later, we find that Shelley has improved her food intake. She increased her protein intake by incorporating legumes, and has even agreed to use some dairy products as she was not liking the plant-based options.The family ate dinners made with meat alternatives in casseroles and soups several nights a week. Shelley's pain subsided and she was able to resume exercising